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SAN 11 FAQ U I N Environmental Health Department —COUNTY - Gr-eotness grows here. Monitoring Well/Soil Boring Inspection Report Date: (I 13�z�z0 Inspector: brldSq CONSTRUCTION Facility Address: _-T�n S fiWW Well Address: Ll Total Depth: WP# D 0 4 d Well#: Drilling Rig Type: Soil Boring#: Min 2"Annular EHD Seal Verified: ❑ Yes ❑No Drilling Company: D) 1y\a Driller Onsite: Screen Length From: To: Consultant: 909VK Filter Pack From: To: Geologist: TBentonite From: To: Grout From: To: Public Water System Onsite: ❑Yes El No COMPLETION ❑ Stove Pipe ❑Christie Box Domestic Well Onsite: ❑ Yes ❑No casing If yes, location and distance: height SAMPLING ABOVE-GROUND Holding Temperature: CO&FLET1ON cCOMPPLETON Method: Grand surrac. Screening Method: grout Verified Chain of Custody: ❑ Yes ❑No ft. ft. ft. SPOILS Contamination Noted: ❑ Yes ❑No If yes,spoils storage Location: abttad =: _ Covered: ❑ Yes ❑No aeon gmvw Pack If yes, material: GROUTING or DESTRUCTION Total Depth: Depth to Water: n Grout Material: Y�_Zm LIW?jn� MATERIALS/DEVELOPMENT Gallons of Grout Used: "-k, y1'UiO.t/►� Casing Type: ❑Well Installation XWell Destruction Blank Feet Screen Feet Slot Size: ❑Boring Installation ❑Boring Destruction Bags iz Cement: METHOD USED Bags Sand/Gravel: ❑Pressure Grout ❑Over Drill Type/Brand of Bentonite: Filter Pack Type/Size: ❑ Gravity 1KTremie ❑Other: Type of Method: Water Cement 471b Water Cement 941b gallons Fall ons Bags Thirk:est Thinnest 41B-Ig s Thi:kest Thinnest 11 Bags Bentonite/Cement Mix 3% Mix 5%. Mix 2.j j i __ j 10 1 bentonite per 47 1b 1.41 2.47 s 10 2 10 20 2 Bentonite per 94 Ib 2.82 4.7 7.5 15 3 15 30 3 10 20 4 20 40 4 12.5 25 5 25 50 5 is 30 6 30 60 6 17.5 35 7 35 70 7 20 40 1 8 40 80 8 10/16/2017 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com